IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF DELAWARE

FEDERAL CIVIL PANEL

Name:

Last, First, MI. (please print)

Law Firm:

Mailing Address:

E-Mail Address:

Telephone:	Ext.:

DE Bar ID#: Date Admitted USDC Bar: ____________________

Willing to accept:	□ Prisoner civil rights cases

□ Employment discrimination cases

□ Other civil cases

Willing to serve as Co-Coordinator? □

Willing to help with educational programs for Panel members? □

Languages:	□ Spoken □ Written

(other than

English)	□ Spoken □ Written

□ Spoken □ Written

I agree to be a member of the Federal Civil Panel as set out in the Court's Standing Order, dated May 25, 1999.

Signature	Date

□ Please provide orientation materials.

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Please return completed form to:	OFFICE OF THE CLERK

UNITED STATES DISTRICT COURT

844 N KING STREET UNIT 18

WILMINGTON DE 19801-3570

ATTN: Ronald B. Eberhard

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